COVID-19 rapid guideline: antibiotics for pneumonia in adults in hospital

Overview

The purpose of this guideline is to ensure the best antibiotic management of suspected or confirmed bacterial pneumonia in adults in hospital during the COVID-19 pandemic. This includes people presenting to hospital with moderate to severe community-acquired pneumonia and people who develop pneumonia while in hospital. It will enable services to make the best use of NHS resources.

Where the new recommendations cover existing recommendations in the NICE guidelines on pneumonia (community-acquired): antimicrobial prescribing and pneumonia (hospital-acquired): antimicrobial prescribing follow the recommendations in the rapid guideline during the pandemic.

This guideline focuses on what you need to stop or start doing during the pandemic. Follow the usual professional guidelines, standards and laws (including those on equalities, safeguarding, communication and mental capacity), as described in making decisions using NICE guidelines.

See a 2-page summary of the prescribing tables to guide decision making about antibiotic choice.

On 9 October 2020, we amended the cefuroxime dosage for adults in line with the summaries of product characteristics.

This guideline is for:

• health and care practitioners
• health and care staff involved in planning and delivering services
• commissioners.

The recommendations bring together:

• existing national and international guidance and policies
• advice from specialists working in the NHS from across the UK. These include people with expertise and experience of treating patients for the specific health conditions covered by the guidance during the current COVID-19 pandemic.

We developed this guideline using the interim process and methods for developing rapid guidelines on COVID-19 in response to the rapidly evolving situation. We will review and update the recommendations as the knowledge base develops using the interim process and methods for guidelines developed in response to health and social care emergencies.

1. Communicating with patients including on treatment and care planning

1.1.

When possible, discuss the risks, benefits and likely outcomes of treatment options with patients with COVID-19, their families and carers, including to help them:

• make informed decisions about their treatment goals and wishes, including treatment escalation plans when appropriate
• understand that COVID-19 pneumonia is caused by a virus, so antibiotics are ineffective unless there is a bacterial co-infection.

1.2.

Find out if patients have advance care plans or advance decisions to refuse treatment, including ‘do not attempt cardiopulmonary resuscitation’ decisions.

1.3.

Use decision support tools (when available). Bear in mind that these discussions may need to take place remotely. Document discussions and decisions clearly, and take account of these in planning care.

1.4.

Provide patients, their families and carers with information that meets their communication needs (see NHS England’s Accessible Information Standard).

1.5.

Discuss with patients, their families and carers about the options for enrolling in a COVID-19 clinical trial.

2. Tests to guide decisions about using antibiotics

2.1.

Consider the following tests to help inform decision making about using antibiotics:

• microbiological samples for routine culture and sensitivities (for example, sputum or tracheal aspirate sample, blood culture)
• SARS-CoV2 polymerase chain reaction assay (nasopharyngeal aspirate, nose and throat swabs, or a lower respiratory tract sample if obtainable); see Public Health England’s guidance on COVID-19: which samples should be taken)
• chest imaging (X-ray, CT or ultrasound)
• full blood count
• legionella and pneumococcal antigen tests (urine sample).

2.2.

There is insufficient evidence to recommend routine procalcitonin testing to guide decisions about antibiotics. Centres already using procalcitonin tests are encouraged to participate in research and data collection (see section 6).

Procalcitonin tests could be useful in identifying whether there is a bacterial infection. However, it is not clear whether they add benefit beyond what is suggested in recommendation 2.1 to guide decisions about antibiotics. The most appropriate threshold for procalcitonin is also uncertain.

2.3.

Be aware that high C-reactive protein levels do not necessarily indicate that the pneumonia is due to bacteria rather than COVID-19.

Published data and clinical opinion suggest that many patients with COVID-19 have raised C-reactive protein levels, meaning that this does not necessarily indicate that there is a bacterial infection.

3. Initial approach to antibiotic treatment choices

3.1.

Be aware that:

• When a patient first presents with suspected pneumonia, it is difficult to differentiate between COVID-19 pneumonia and bacterial pneumonia on clinical features alone (see recommendations 4.2 and 4.3).
• During the COVID-19 pandemic to date most pneumonia has been viral. Evidence so far suggests that bacterial co-infection occurs in less than about 10% of patients with COVID-19. But patients in critical care have an increased likelihood of bacterial infection compared with patients in other hospital wards or settings.
• Because COVID-19 pneumonia is caused by a virus, antibiotics are ineffective unless there is a bacterial co-infection.
• Inappropriate antibiotic use may reduce their availability, and indiscriminate use may lead to Clostridioides difficile infection and antimicrobial resistance.

Antibiotic choice

3.4.

To guide decision making about antibiotics, use:

• antibiotic prescribing table 1 for patients with suspected community-acquired pneumonia (that is, pneumonia that has developed before or within 48 hours of admission)
• antibiotic prescribing table 2 for patients with suspected hospital acquired pneumonia (that is, pneumonia that develops 48 hours or more after admission and that was not incubating at admission).

3.5.

When choosing antibiotics, take account of:

• local antimicrobial resistance data and
• other factors such as their availability.

3.6.

For patients who are already taking an antibiotic that was started in the community for suspected pneumonia:

• review the antibiotic choice and
• change the antibiotic in line with antibiotic prescribing table 1, if appropriate.

3.7.

Give oral antibiotics if the patient can take oral medicines and their condition is not severe enough to need intravenous antibiotics.

3.8.

Seek specialist advice on antibiotic treatment for patients who:

• are immunocompromised
• have a history of infection with resistant organisms
• have a history of repeated infective exacerbations of lung disease
• are pregnant
• are in critical care.

Prescribing tables to guide decision making about antibiotic choice

A 2-page summary version of these prescribing tables is also available to download.

Table 1

Antibiotics for people 18 and older with suspected community-acquired pneumonia [amended 9 October 2020].

See the BNF for appropriate use and dosing in specific populations, for example, for hepatic impairment, renal impairment, pregnancy and breast-feeding, and when administering intravenous antibiotics.

There are no validated tools to assess the severity of community-acquired pneumonia in the context of the COVID-19 pandemic; severity should be based on clinical judgement.

Consult a local microbiologist for alternative options, including for pregnant women.

If there is a penicillin allergy, avoid using co-amoxiclav and use cefuroxime with caution.

For safety issues with fluoroquinolones, see the Medicines and Healthcare products Regulatory Agency advice. This covers restrictions and precautions for using fluoroquinolone antibiotics because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at the first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

Table 2

Antibiotics for people 18 and older with suspected hospital-acquired pneumonia.

See the BNF for appropriate use and dosing in specific populations, for example, for hepatic impairment, renal impairment, pregnancy and breast-feeding, and when administering intravenous antibiotics.

There are no validated tools to assess the severity of hospital-acquired pneumonia in the context of the COVID-19 pandemic; severity should be based on clinical judgement.

Consult a local microbiologist for alternative options, including for pregnant women.

If there is a penicillin allergy, avoid using co-amoxiclav and piperacillin with tazobactam, and use cefuroxime and ceftazidime with caution.

Higher risk of resistance includes symptoms or signs starting more than 5 days after hospital admission, relevant comorbidity such as severe lung disease or immunosuppression, recent use of broad-spectrum antibiotics, colonisation with multidrug-resistant bacteria, and recent contact with a health or social care setting before current admission.

For antibiotics not licensed for hospital-acquired pneumonia (co-trimoxazole, levofloxacin), use would be off-label. See NICE’s prescribing medicines for more information.

For safety issues with fluoroquinolones, see the Medicines and Healthcare products Regulatory Agency advice. This covers restrictions and precautions for using fluoroquinolone antibiotics because of very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at the first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution for people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

4. Assessing the ongoing need for antibiotics

4.1.

Review all antibiotics at 24 to 48 hours or as soon as test results are available.

5. Reassessment and specialist advice

5.1.

Reassess patients if their symptoms do not improve as expected, or worsen rapidly or significantly.

5.2.

Seek specialist advice if:

• there is a suspicion that the patient has an infection with multidrug-resistant bacteria and may need a different antibiotic, or
• there is clinical or microbiological evidence of infection and the patient’s condition does not improve as expected after 48 to 72 hours of antibiotic treatment.

6. Research recommendations

6.1.

Further research is recommended to:

• help improve understanding about the value added by procalcitonin testing when used with clinical judgement
• guide decisions about stopping antibiotics for people admitted to hospital with pneumonia in the context of the COVID-19 pandemic.

Table

P: Adults admitted to hospital with suspected COVID-19 pneumonia I: Procalcitonin-guided antibiotic therapy

Update information

9 October 2020: We amended the cefuroxime dosage for adults in line with the summaries of product characteristics.